How physicians use knowledge of child trauma to help adult patients with chronic disease

Editor's note: This is the sixth in a series of posts that accompany questions from the simple version of the ACE Study questionnaire developed by the Centers for Disease Control and Prevention. There are 10 questions on the simple ACE Study questionnaire; we posted the first five in polls last week and we're posting the rest this week. Today is the sixth question. Each day I'll take a look at some of the research — ACE, brain development, and epigenetics (the study of how experiences turn genes on and off) — to provide more information and context. I encourage you to take the simple ACE test for yourself. There's also a link to the full 200-question survey.

If the link between child trauma and the adult onset of chronic illness is so clear, why don't all physicians use it in their practice?

When physicians at Kaiser Permanente, where the Adverse Childhood Experience Study took place, began asking patients about their childhood trauma (the biopsychosocial approach vs. a biomedical approach, below), an interesting phenomenon took place -- they made fewer visits to doctors.

In the Q-and-A following the webinar, Felitti answered these questions. The questions and answers are abbreviated and edited here. For the entire exchange, listen to the session.

Q. Does the decrease in doctor visits have to do with basic recognition of issues that underlie individual's behavior?

We have wrestled with that question for a long time. People have said to me, "You sent everyone for therapy, right?" No, rarely did we do that. What we did was to routinely ask about things kept secret, to enable people to speak openly about these topics, and we made it clear to them that they were acceptable to us as human beings. This all took place in a space of a few minutes. Does this mean that people are healthier? We don't know. They appear to be less troubled. By the way, doctor's office visits are not driven by disease, but by anxiety about disease.

Q. What would be a good lead-in question to get used to discuss these issues?

We have had enormous experience in using extensive paper-based questionnaires that were filled out by hand. Then we fed the questionnaire into a digital scanner, and it was reformatted into a formatted laser output. What we had in hand when we saw patients was really quite extraordinary. It made it possible for us to ask things like: I see on the questionnaire that you were the one who discovered your father's body when he hanged himself. Tell me how that's affect you later in your life. Or I see that you were molested when you were a kid. Tell me how that's affected you later in your life. Once it's out, then it's easier to bring it up. You know where you can go or don't need to go. The key question you want to pose is: Tell me how that's affected you later in your life. We have done this with enormous numbers of people -- over 440,000 people over 8 years -- very, very successfully.

Of course, not everybody was instantly comfortable doing this. But most of the staff became remarkably adept at doing this. The answers do not open a Pandora's Box. My colleagues initially said, I don't have an hour to listen. The answers tended to be one to one-and-a-half minutes long, often including information that enable a physician to figure out what he needed to do.

A. You said that using information clinically will be resisted? What is typical rationale, and what do you recommend that be overcome?

I think the true basis of resistance is that this approach awakens personal ghosts in us. Seemingly plausible explanations are that insurance doesn't cover it, I don't have time. All of those are partially real. Another reason that people correctly offer is that they've never been trained to do that kind of work. "If i'd been trained to be a shrink, then i would've been a shrink. I'm a pediatric endocrinologist," for example. But I think it's mostly that it awakens personal ghosts.
This approach -- asking patients about their child trauma and how it affects their health -- represents a paradigm shift in primary care practices. This is not a minor shift.

Dr. Eric Blau, a Kaiser physician who worked with Felitti, provides some additional insight. “When the study was first being done,” says Blau, "I was shocked and didn’t believe it. It goes against everything we’re taught about why people get sick later in life. That’s related to genetics or things that happen to you as an adult.”

And though he now calls the study groundbreaking, Blau explains why the medical community just doesn’t know what to do with it.

“I can give you the cynic’s point of view. There’s no cure, so why are you bothering to ask patients about their childhoods? If they’re smoking because they were abused at age 5, what good is it to know? It’s better just to deal with cigarette addiction. And another view is that a lot of people just don’t have time in their offices to deal with this.”

Even though the ACE Study offers awareness, but no treatment, Blau still uses it in his practice.

“I ask them questions about their lives,” says Blau. “If they weigh 100 pounds more than they should, I don’t think it’s their genetics. I ask them when they got fat. People get fat because of things that happen to them as children. If you ask about this, then you can get to the root of the problem. We may not have a good therapy, but at least we can identify the problem. Sometimes it helps them, sometimes it doesn’t.”

The public health community, however, is beginning to embrace the study. Five states have included the ACE questionnaire in their Behavioral Risk Factor Surveillance System. Every state has one, and uses it to determine its population’s health so that it can put resources where they are needed to prevent illness, such as heart disease and lung cancer.

“For the first time, this will give us some population based data,” said Dr. David Brown, a CDC epidemiologist. “I fully expect data that comes out of states is going to support what we’ve seen in Kaiser data.”

He likens the slow acceptance of the ACE Study to another large public health issue — the dangers of high blood pressure. The first data about high blood cholesterol was gathered nationally in the late 1980s. Then pharmaceutical companies began doing clinical trials with cholesterol-reducing drugs. In the mid- to late-1990s, states began starting programs in heart disease and stroke. Between 2000 and 2005, all states offered programs. All of that came out of the Framingham Heart Study in Massachusetts, which began with a few thousand people in the 1950s. “That’s a long process,” says Brown. “That’s kind of where the ACE Study is at as well.”